“I hope that the 600,000 French people with chronic illnesses who do not have a doctor will be able to have them by the end of the year”. This announcement, Emmanuel Macron made it in his wishes to the caregivers of the January 6before reiterating it in his speech on April 17 last. By tackling this problem, it is to be feared that the President of the Republic will mainly focus on statistics, without really improving access to care.
What are we talking about ? In the administrative databases of the Health Insurance, there are patients registered as suffering from a long-term illness (ALD) and having no attending physician. According to Health Insurance, patients in this situation would be 714,000 in December 2022 – and not 600,000 according to the figure given by Emmanuel Macron (June 2021 figure).
The good news is that this number can be reduced very quickly, from a purely administrative point of view. There are several obvious levers:
1. Correct lost or forgotten “attending physician” statements. There are plenty of reasons: a deferred declaration (after the 2nd or 3rd consultation), a piece of paper forgotten, lost, or even a declaration deleted on the occasion of a change of fund or if the doctor has become an employee (loss of his ADELI number). In March 2023, Health Insurance estimated that 183,000 ALD patients aged 17 and over consulted the same doctor at least three times during the year, without the latter being considered their attending physician: 25% of ALD patients without attending physician are therefore already followed in practice. Health Insurance will contact these patients in April 2023 and then their general practitioners in May, in order to regularize these administrative oversights. It is a pity to have set the threshold at three consultations in the year: we will miss patients in this situation, but followed once or twice a year…
2. Encourage specialists “treating physicians” to declare themselves (nephrologists, geriatricians, etc.). Any doctor can be declared a general practitioner in theory, but this is rarely used in practice… Thus, the 50,000 patients on dialysis in France are monitored (often in hospitals) every two days, and consult their nephrologist every one to three month. Some don’t have a general practitioner, but is that really a problem? More anecdotally, some patients may be hospitalized for a long time, during which their doctor may retire (follow-up care and rehabilitation, psychiatry, neurology in particular), others may have ALD requiring only annual follow-up or half-yearly (especially well-balanced patients among the 3.2 million with ALD for diabetes, cured patients among the 2.4 million with 5-year ALD for malignancy, etc.), or even ALD without drug treatment and a risk of leaving care (cognitive disorders in particular). In March 2023Health Insurance reports that ALD patients without an attending physician seek care less: 20% have not seen any general practitioner in town compared to 4% of ALD patients with an attending physician: this can of course be linked to impossibility of finding a general practitioner, or the uselessness of finding one within the framework of monitoring by another specialist, or within the framework of institutionalization (Ehpad, long stay, etc.).
3. Affiliate all the patients of a young retired doctor to a “territorial treating team”. According to DREES figuresthere were 64,142 general practitioners in exclusive private practice in 2012 and 57,033 in 2022… i.e. an average of 700 fewer general practitioners per year (or 800 according to the forecasts of the National Council of the Order of Physicians in 2018). Assuming that each GP follows around 200 patients among the approximately 10 million in ALD in Francethis leaves 140,000 new ALD patients without a general practitioner per year, with a 3-6 month prescription before finding a new doctor, who will perhaps wait for the 2nd or 3rd consultation to co-sign the general practitioner declaration… In the meantime, according to the president’s desire to have a “treating team”, it will always be easy to attach these patients to a new territorial entity, even if there is no medical follow-up provided for by default of doctors.
4. Affiliate all nursing home patients to an “ehpad treating team”. In 2015 according to the DREES, 730,000 patients are accommodated in residential establishments for the elderly, including 32,790 in long-stay units (hospital units where general practitioners cannot monitor their patients). About 30% of nursing homes have a global budget: general practitioners do not have physical access to their residents’ vital cards and in this context, declarations are not made, or by paper with multiple occasions for non-declaration ( forgetting to send, sending to the wrong fund, etc.). Health Insurance announces 8.5% of patients in nursing homes without a declaration from a treating doctor, i.e. 62,000 patients, yet benefiting from paramedical follow-up as presented by the president in his “treating team” project. It is also likely that in the 20% of ALD patients who have not seen a general practitioner during the year, there are many patients in nursing homes. Here again, the administrative problem can be solved by creating an entity “Ehpad treating team” which will improve the statistics without changing anything to the difficulties of access to follow-up by a general practitioner in an Ehpad.
We have just listed the means of reducing the number of ALD patients without an attending physician. But there are other situations that could on the contrary increase it:
1. Delete “treating doctor” declarations when a doctor stops monitoring his patient entering an nursing home. Indeed, it is common for a doctor to remain declared as the attending physician of an institutionalized patient, even though he has decided not to follow him, for reasons of remoteness (change of region or distance from the nursing home) or by choice. We know that 4% of ALD patients with a general practitioner have not seen a general practitioner during the year: how many are in nursing homes?
2. Correct under-reporting of ALDs. It is well known that certain pathologies are under-diagnosed or under-reported: for example, there are 368,800 patients with ALD15 (Alzheimer’s disease and other dementias) while 1.2 million patients would be affectedi.e. a ratio of 1/3 declared in ALD (lack of identification, reluctance to do the tests, undesired declaration, etc.)
3. Correct missing follow-up for some patients. ALDs are almost always declared by general practitioners; thus, if there is no general practitioner, there is no ALD, and therefore no ALD patient without a general practitioner…
The diagnosis therefore deserves to be refined: there are many patients without a general practitioner (in ALD or not), but also patients in ALD with a declared general practitioner but without follow-up (in particular in Ehpad) who will be masked in this quest for 0 ALD patient without attending physician.
After the diagnosis comes the time for treatment: the symptoms can be treated (correct administrative non-declarations, attach patients to a “treating team”, etc.), but this will not change the basic problem if the medical time does not not increase. We have listed a few ways to fluctuate the number of ALD patients without a general practitioner in one direction or the other, depending on the presidential objectives. But in the end, is it so important? Admittedly, this will at least be a political success for the President next January, when the administrative anomalies will have been dealt with… We will devote a lot of energy to fixing the figures, but the French will for the most part not see any effect from these measures if nothing is done to improve the medical time available.
The increase in available medical time should therefore be the priority over access to care, with in particular three concrete levers of action that are insufficiently highlighted:
– Reduce unnecessary care tasks, such as those relayed recently by the College of General Medicine through the site certificates-absurdes.fr (removal of medical certificates for short work stoppages and absence for sick children in particular).
– Continue the delegation of tasks by opening up reimbursement to other health professionals whose actions in terms of prevention are recognized (dieticians, psychologists, occupational therapists).
– Reduce the reasons for seeking care through preventive actions against tobacco, alcohol, obesity, but also infections through the air quality improvement plan promised by candidate Emmanuel Macron at a meeting on April 16, 2022, the effects of which in schools were expected at the end of 2022 (reduction of respiratory infections, reduction of allergies, improvement in student concentration, reduction in absenteeism and medical consultations, etc.)
It is by reducing consultations through prevention and simplification measures that we will allow doctors to find time to follow patients in nursing homes or to continue to accept new patients following the retirement of their colleagues. Without that, we will look after our administrative databases more than our fellow citizens.
* Dr Michaël Rochoy is a general practitioner in Pas-de-Calais.